Early vs Delayed Cerebral Infarction After Aneurysm Repair After Subarachnoid Hemorrhage

Kumar, Abhay; Brown, Robert; Dhar, Rajat; Sampson, Tomoko Rie; Derdeyn, Colin P.; Moran, Christopher J.; Diringer, Michael N.

doi:10.1227/neu.0000000000000057

Cited by 33 publications

(24 citation statements)

References 24 publications

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“…Studies have often focused on cerebral infarction identified at long-term follow-up with imaging 3,12,[25][26][27] or have only identified infarcts on imaging in patients who became symptomatic and were subsequently imaged in hospital. 8,13 These strategies may significantly underestimate the incidence of both early and delayed infarction. The current study is the first to examine the frequency of early procedure-related and delayed cerebral infarction in a prospectively collected and protocol-driven data set and to directly compare differences between patients treated by clipping or coiling.…”

Section: Discussionmentioning

confidence: 99%

“…Infarction may occur as early brain injury because of initial aneurysm rupture, [4][5][6] or as delayed cerebral ischemia, 7 often attributed to arterial vasospasm. 5,8,9 Increasingly, evidence also points to infarction as a result of iatrogenic injury caused by either neurosurgical clipping 2,8 or endovascular coiling. 10,11 Recent studies have revealed a dissociation between early and delayed cerebral infarction with respect to their contributions to neurological outcomes.…”

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confidence: 99%

“…2,12 Additionally, their retrospective design precluded the inference of strong conclusions. 8,13 In the current study, we analyzed clinical features that were associated with early (24-48 hours after aneurysm repair) and delayed (6 weeks after aSAH) cerebral infarcts identified on computed tomography (CT) scans of patients enrolled in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage).…”

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confidence: 99%

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Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Ayling

Ibrahim

Alotaibi

et al. 2016

Stroke

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Background and Purpose-Cerebral infarction after aneurysmal subarachnoid hemorrhage is a significant cause of substantial morbidity and mortality. Because early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage may be mediated by different processes, we evaluated whether aneurysm-securing methods contributed to infarcts and whether long-term outcomes differ between early and delayed infarcts. Methods-A post hoc analysis of the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage) was performed. Using multivariate logistic regression analysis and propensity matching, independent clinical risk factors associated with infarctions were identified, and the contribution of cerebral infarcts to long-term outcomes was evaluated. Results-Within the cohort of 413 subjects, early infarcts were present in 76 subjects (18%), whereas delayed infarcts occurred in 79 subjects (19%), and 36 subjects (9%) had new infarctions that were present on both early and delayed imaging. Propensity score matching revealed a significantly higher proportion of early infarcts after clipping (odds ratio, 4.62; 95% confidence interval, 1.99-11.57; P=0.00012). Multivariate logistic regressions identified clipping as an independent risk factor for early cerebral infarction (odds ratio, 0.26; 95% confidence interval, 0.15-0.48; P<0.001), and angiographic vasospasm was an independent risk factor for delayed cerebral infarction (odds ratio, 1.79; 95% confidence interval, 1.03-3.13; P=0.039). Early infarcts were a significant independent risk factor for poor long-term outcomes at 3 months (odds ratio, 2.34; 95% confidence interval, 1.18-4.67; P=0.015). Conclusions-Clipping is an independent risk factor for the development of early cerebral infarcts, whereas delayed cerebral infarcts are associated with angiographic vasospasm. Early cerebral infarcts are stronger predictors of worse outcome than delayed infarction. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00111085.

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confidence: 99%

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Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Ayling

Ibrahim

Alotaibi

et al. 2016

Stroke

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“…We believe that these morbidities are within the range of accepted rates for these procedures; according to published surgical series, clinically significant postoperative hematomas occur in 1%-4% of patients following glioma surgery, 9,27 postoperative vascular injury occur in 2%-3% of patients following resection of VS, 26 and early postoperative cerebral infarction associated with aneurysm clipping occur in 11% of the cases of rupture aneurysms. 19 Taken into entirety, these complications were attributed to the complexity of the cases and the patient's comorbidities, rather than the optical performance of the ROVOT-m. Notably, the PICA artery laceration that was experienced while resecting a VS was, despite the significant bleeding, effectively controlled with the ROVOT-m exclusively and without the need for intraoperative conversion to CS-m.…”

Section: Rovot-m Safetymentioning

confidence: 99%

Initial experience with a robotically operated video optical telescopic-microscope in cranial neurosurgery: feasibility, safety, and clinical applications

Gonen

Chakravarthi

Monroy-Sosa

et al. 2017

Neurosurgical Focus

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OBJECTIVEThe move toward better, more effective optical visualization in the field of neurosurgery has been a focus of technological innovation. In this study, the authors’ objectives are to describe the feasibility and safety of a new robotic optical platform, namely, the robotically operated video optical telescopic-microscope (ROVOT-m), in cranial microsurgical applications.METHODSA prospective database comprising patients who underwent a cranial procedure between April 2015 and September 2016 was queried, and the first 200 patients who met the inclusion criteria were selected as the cohort for a retrospective chart review. Only adults who underwent microsurgical procedures in which the ROVOT-m was used were considered for the study. Preoperative, intraoperative, and postoperative data were retrieved from electronic medical records. The authors address the feasibility and safety of the ROVOT-m by studying various intraoperative variables and by reporting perioperative morbidity and mortality, respectively. To assess the learning curve, cranial procedures were categorized into 6 progressively increasing complexity groups. The main categories of pathology were I) intracerebral hemorrhages (ICHs); II) intraaxial tumors involving noneloquent regions or noncomplex extraaxial tumors; III) intraaxial tumors involving eloquent regions; IV) skull base pathologies; V) intraventricular lesions; and VI) cerebrovascular lesions. In addition, the entire cohort was evenly divided into early and late cohorts.RESULTSThe patient cohort comprised 104 female (52%) and 96 male (48%) patients with a mean age of 56.7 years. The most common pathological entities encountered were neoplastic lesions (153, 76.5%), followed by ICH (20, 10%). The distribution of cases by complexity categories was 11.5%, 36.5%, 22%, 20%, 3.5%, and 6.5% for Categories I, II, II, IV, V, and VI, respectively. In all 200 cases, the surgical goal was achieved without the need for intraoperative conversion. Overall, the authors encountered 3 (1.5%) major neurological morbidities and 6 (3%) 30-day mortalities. Four of the 6 deaths were in the ICH group, resulting in a 1% mortality rate for the remainder of the cohort when excluding these patients. None of the intraoperative complications were considered to be attributable to the visualization provided by the ROVOT-m. When comparing the early and late cohorts, the authors noticed an increase in the proportion of higher-complexity surgeries (Categories IV–VI), from 23% in the early cohort, to 37% in the late cohort (p = 0.030). In addition, a significant reduction in operating room setup time was demonstrated (p < 0.01).CONCLUSIONSThe feasibility and safety of the ROVOT-m was demonstrated in a wide range of cranial microsurgical applications. The authors report a gradual increase in case complexity over time, representing an incremental acquisition of experience with this technology. A learning curve of both setup and execution phases should be anticipated by new adopters of the robot system. Further prospective studies are required to address the efficacy of ROVOT-m. This system may play a role in neurosurgery as an integrated platform that is applicable to a variety of cranial procedures.

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“…The total hypodense area for each patient was calculated as the sum of all individual hypodense volumes. 12 In the subgroup in which the initial cerebral edema volume was greater than the median volume (18 ml), chronological change of the cerebral edema was analyzed by comparing hypodense areas on the postoperative Day 1 and discharge CT scans.…”

Section: Radiological Evaluationmentioning

confidence: 99%

Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage

Fukuda¹,

Hayashi²,

Moriya

et al. 2015

JNS

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P atients who present with a poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and has distinct features. 2,18,19 Poor-grade SAH with ISH has been considered to be less associated with severe initial injury and regarded as a potential responder to intensive treatment. 2,19,20 The purpose of this study is to clarify whether the presence of ISH predicts good functional recovery from poor-grade aneurysmal SAH. MethodsThe study is reported based on criteria from the STROBE (Strengthening the Reporting of Observational abbreviatioNs ICH = intracerebral hematoma; ISH = intrasylvian hematoma; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies. obJect Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and often presents with a poor initial neurological grade; it is not well studied. The aim of this study was to elucidate outcomes of aneurysmal subarachnoid hemorrhage (SAH) with ISH. Methods Data for 97 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grade IV or V) were retrospectively analyzed from a single-center, prospective, observational cohort database. Ultra-early surgical clipping, removal of hematoma, external decompression for brain swelling, and prevention of vasospasm by cisternal irrigation with milrinone were combined as an aggressive treatment. Characteristics and clinical courses of SAH with ISH were identified. The authors also evaluated any correlations between poor admission-grade SAH and ISH with good functional outcome. results Patients with poor admission-grade SAH and with ISH were more likely to have initial cerebral edema (p < 0.001, Mann-Whitney U-test), which significantly resolved over time (p < 0.001, Mann-Whitney U-test). These patients had a better chance of functional survival (modified Rankin Scale scores of 1-3; OR 5.75; 95% CI 1.36-24.3; p = 0.017) at 6 months after hospital discharge, after adjustment for potential confounders such as younger age and better initial neurological grade by multivariable analysis. coNclusioNs ISH predicted good functional recovery from poor-grade aneurysmal SAH.

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Early vs Delayed Cerebral Infarction After Aneurysm Repair After Subarachnoid Hemorrhage

Abstract: Early infarction occurs frequently after SAH and contributes as much as delayed cerebral ischemia to infarct burden and hospital outcome. Efforts to better understand and modify contributors to early infarction appear warranted.

Cited by 33 publications

References 24 publications

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Dissociation of Early and Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Initial experience with a robotically operated video optical telescopic-microscope in cranial neurosurgery: feasibility, safety, and clinical applications

Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage

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